Ankle Fracture denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an inpatient admission. The risk of compartment syndrome is a known and devastating complication of trauma. As noted in the medical literature, “acute complications of ankle fractures, such as injuries to peripheral nerves or vascular structures, open fractures, and compartment syndrome, are readily identified in most cases and require immediate surgical consultation”.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for six additional physical therapy sessions. The requested physical therapy is generally accepted as an effective therapy for loss of mobility after an ankle fracture and lateral epicondylitis or tennis elbow. The patient underwent surgery (open reduction and internal fixation) for her left ankle fracture and developed bilateral lateral epicondylitis after using crutches for assistance with ambulation given her ankle fractures. While the patient has received 36 sessions of physical therapy, she does have multiple medical issues, including fractures of both ankles with reduced range of motion and mobility, as well as lateral epicondylitis of both elbows that has required injections.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility services. There is a paucity of evidence in current medical literature supporting significant rehabilitation interventions, outside of obtaining compensatory skills, following significant lower limb fractures. Researchers reported little evidence for rehabilitation interventions during the immobilization period after conservative orthopedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilization period. Researchers found that a supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture.

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility care for treatment of his medical condition. Findings: The physician reviewer found that the medical literature does not indicate whether the long-term outcomes in adults with ankle fracture are superior with surgical versus conservative treatment (Donken, et al). In addition, there is limited high quality data published with respect to specific rehabilitation measures following conservatively managed ankle fractures (Lin, et al). In this case, the patient sustained an ankle fracture and has been immobilized with non-weight bearing restrictions. He would have been expected to have improved to a fully independent ambulator with crutches and fully independent with all of his self-care on the basis of an ankle fracture, even with ongoing non-weight bearing restrictions.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving ankle fracture, then check the rights and deadlines that apply to your plan.